Forgoing fluoroscopy in favor of intracardiac echocardiography (ICE) to guide catheter ablation of atrial fibrillation (AFib) is not only feasible but highly desirable, as the ultrasound-based choice can squash radiation exposure for patients and care workers alike. Yet ICE has failed to catch on with electrophysiologists even after several years of ready availability. Why is that?

Because old habits are hard to break—but in this case can and should be, argue Cornell University researchers in a how-to article running in the June edition of Heart Rhythm.

In making their case, Bruce Lerman, MD, and colleagues acknowledge that “fluoroless” AFib ablation is not always achievable. This is the case when, for example, the patient has preexisting pacemaker or defibrillator leads, anatomic anomalies or poor acoustic windows.

“In these circumstances, since safety is always the highest priority, short flashes of fluoroscopy may be appropriate,” they write.

That said, they add, their teams at NewYork Presbyterian and Weill Cornell Medicine are going fluoroless in approximately 70 percent of patients—and using less than 60 seconds of fluoroscopy in nearly 90 percent.

In a press release sent by Weill Cornell, Lerman says patients undergoing traditional fluoroscopy-guided AFib ablation are hit with radiation doses about equal to what they would receive in 830 x-rays.

“In our hands, the vast majority of AFib patients do not require fluoroscopy, resulting in no radiation exposure to the patient or the electrophysiologist performing the procedure,” says Lerman, who serves his institution as cardiology chief and director of cardiac electrophysiology.

The ICE system they use combines pre-procedural imaging data with computerized 3D mapping systems.

“For some, the learning curve can be steep, but generally, the skill set can be readily acquired,” says Jim Cheung, MD. “We are currently training our fellows to utilize this technique in an effort to guide the next generation of cardiologists to become well-versed in fluoroless ablation.”

“The most critical requisite for performing fluoroless catheter ablation of AFib is a willingness to relinquish an old habit,” Lerman underscores.

The press release notes that both Lerman and Cheung are consultants with electrophysiology device maker Biosense Webster.